New Outpatient Radiology Ordering Process: Prior Approvals for CT, CTA, MRI, MRA, Cardiac Nuclear, and PET Procedures Now Required

Prior approval for CT, CTA, MRI, MRA, Cardiac Nuclear, and PET procedures will be required for dates of service of April 18, 2011 and forward. The New York State Medicaid Fee for Service (FFS) Program has begun implementation of RadConsult™, a radiology benefits management program designed to ensure that beneficiaries receive the most clinically appropriate imaging studies.

RadConsult participation does not apply to beneficiaries eligible for both Medicaid and Medicare (dual eligible) or those enrolled in a managed care plan. RadConsult, administered by HealthHelp, works to improve health care quality and reduce cost of care by providing expert peer consultation and the latest evidence-based medical criteria for diagnostic imaging.

Subspecialty radiologists are also accessible through the program.

Ordering physicians will obtain prior approval for CT, CTA, MRI, MRA, cardiac nuclear medicine, and PET through RadConsult, which will review the request against existing guidelines. Imaging procedures provided in house also require prior approval to be processed to ensure payment of claims. Ordering physicians can make requests by phone, fax, and online through the RadConsult Web tool. Imaging practitioners will have access to RadConsult to confirm prior approval has been obtained through the ordering provider. Payment of claims requires prior approval.

If a request does not meet RadConsult guidelines, the ordering physicians will receive documentationsupporting best practices and will have the opportunity to consult with a HealthHelp radiologist.

Further Information:
Educational materials and program information can be found on the Radiology Prior Approval webpage on EMedNY.